Leicester City’s response to the COVID-19 pandemic started with a strong Home first ethos already in place:
- The Urgent Community Response service was achieving nearly 100 per cent of responses within two hours and had an average 29 minute response time to people experiencing a fall.
- The wider council delivers vital preventative services such as a dedicated handy person service and an in-house community alarm service.
- Had started as one of seven ‘accelerator’ sites to roll out Urgent Care Response teams across the Leicester, Leicestershire and Rutland (LLR) footprint.
- So with this commitment to meeting the two hour/two day response times already in place, and with the support of staff, it was possible to step therapy up to seven days.
- Following a successful pilot, a D2A@H (discharge to assess at home) service was in place and facilitating timely discharges, improving outcomes and experiences for those who might otherwise have waited in hospital for a CHC assessment.
When the pandemic hit, Leicester City signed up to the East Midlands Memorandum of Understanding which supplements the Discharge Requirements and promotes a Home First ethos. It also developed its discharge pathways further, worked with LLR to establish a discharge coordination hub supported by the Urgent Community Response and D2A@H services, and enhanced its intelligence and insight to help it manage its response.
The Leicester City, Leicestershire and Rutland (LLR) systems have worked together to develop and agree guidance, protocols, pathways and a Memorandum of Understanding that support the implementation of the Hospital Discharge Guidance.
- There are twice daily ‘board rounds’ when patients are assessed against the ‘maintaining good decision making in acute settings’ criteria. If medically optimised then the Nerve Centre is updated to identify whether or not the patient being discharged needs some form of support. Setting the criteria for discharge enables the MDT team to discharge patients throughout the day.
- A Home First referral form is used to record identified needs and then if the patient can manage at home with community nursing or domiciliary care support this is arranged in order that patients go home.
- If it is unclear whether the patient can manage at home they are admitted to a nursing home where a virtual meeting is arranged so that the MDT review can be completed within 24 hours. This then informs whether the patient goes home with support or remains in the setting for a longer term assessment.
- There is also an end of life pathway for patients requiring care packages with different routes depending on whether the person is in the last week of life.
- The pathways are managed using multi-agency daily/ twice daily sitrep calls every morning with conversations about every person, and issues going to the 12:30 call and then escalated if needed after that.
- A ‘Tiger Team’ trouble shoots and resolve issues. This collaboration of managers from across LLR review at the discharge system to see what is working and what isn’t; their current focus is the model for discharge in the medium term.
Pathway one: discharge to assess
A LLR discharge coordination hub was established to manage the discharge of patients leaving University Hospitals of Leicester NHS Trust, LPT community hospitals and Out of Area referrals from a single point. The good will of staff and their 'can do attitude' meant the hub was able to provide 7 day extended access.
Patients discharged on Pathway one receive calls from care navigators who follow up on how they are managing and whether they might need more support. Adult social care staff also rang many thousands of people who were on the NHS Shielding List to see if they need help.
Trusted assessments were already in place, removing the need for social workers to go on to wards.
The Integrated Crisis Response Service (UCR) prepared for an increase in activity which gave them the capacity to take on a greater role in discharge and to maintain capacity in reablement. Reablement took the opportunity to review and then streamline processes to support people moving onto mainstream services as soon as they had reached their improvement potential.
The cessation of continuing health care (CHC) assessments freed up staff to support the sourcing care packages for those patients with complex needs who were being referred to adult social care instead.
Having successfully engaged the domiciliary care market during a recent reprocurement, the Council’s Brokerage Service was able to jointly commission providers to respond to COVID-19 on behalf of health and social care. The link officer role, connecting providers with the team, meant that the market was able to provide a 36 per cent increase in newly commissioned care between 19 March and 31 May 31 2020 compared with the same period last year. The council supported providers by moving to paying four weeks in advance and paying a higher contact fee that reflects the additional costs associated with PPE and the extra time needed to deliver care safely while following infection control guidance.
Pathway two: bedded rehabilitation
The LLR Discharge Pathway to Care Home During COVID-19 protocol requires hospital inpatients be tested prior to discharge into a care home setting, and sets out the isolation requirements whether individuals have had a COVID positive test, COVID negative result or are still awaiting the results of a test.
At the outset of the pandemic, the Council procured a 15 bedded unit where people who were COVID-19 positive could stay for up to 14 days following discharge; and from where they could have their assessment.
Additional payments were made to care homes, and supported living organisations, to reflect their cost pressures resulting from higher staff sickness absence rates and associated agency and PPE costs. These payments equated to 10% of the weekly care package costs and were paid from 19 March 2020 to 5 June 2020, amounting to an extra £1.235million.
Payments were also made to care homes outside Leicester to recognise the placements made by the Council outside its boundary.
Leicester City Council took the decision to merge all of their PPE stock and gave priority to the care homes and domiciliary care providers.
Experience of local lockdown
Since the original interviews, Leicester became the first city to be subject to a local lockdown as a result of the number of COVID-19 cases in the area. Following the height of the pandemic, local arrangements have been reviewed and adjustments made to the discharge pathways: There was an initial reduction in demand on adult social care. For example the number of requests for support prompted by hospital discharge dropped in April to 143, which is 90 fewer than in March and 77 fewer than the 2019/20 monthly average.
The initial reduction in referrals for reablement was attributed to a combination of elective surgeries not happening, the cohort of people in hospital being far more unwell than previously and fewer people being deemed eligible.
The therapy presence on the wards has since increased and the referrals for reablement are going back up; patients are less likely to be placed on Pathway two. For example, in May there were 35 people on the reablement pathway compared with 120 in the same month in 2019, by June this had increased to 66. Work is underway to review and reset the discharge pathway for the future; this reset will including finding robust routes to care homes with trusted assessments.
In the event, happily fewer people than expected needed to use the COVID+ beds that had been procured; and as the arrangement is no longer needed it is in the process of being stepped down.
When CHC assessments resume in September, the newly agreed Shared Care Process, which had been put on hold, will be restarted. This is a process designed to expedite decision making for shared care and funding arrangements for patients who are not eligible for continuing health care but who have recognised health care needs. The volume of telephone calls received in April dropped significantly however the extended lockdown has increased demand for support, with people’s resilience being reduced.
The City Council is noticing the extent to which people are seeking support from adult social care because other support is limited or not available. This is particularly the case with mental health and primary care support. Pathway one casework has highlighted this, with people requiring support to access health services and support with isolation.
Critical success factors
- “A lot of this has shown that it’s the relationships between professionals that gets things done rather than a flow chart on a powerpoint or document somewhere. It’s not what people remember, it’s that I need to ring so and so”
- “You can put in what tools you like, but without they won’t work without relationships”
- “Collaboration - the concept of a 'team' changed”
- “Relationships are critical; if you can't get them right then you won't be able to solve any problems”
- "Support the market."
- "Named link officer."